Tuesday, December 21, 2010

Emergency, as per the all-knowing Webster, is defined as an unforeseen combination of circumstances or the resulting state that calls for immediate action. Furthermore, an emergency is also defined as an urgent need for assistance or relief.

These definitions sound pretty spot-on, right? When thinking about emergency room settings, even, one can easily correlate the words of Webster to what one would necessitate to be a situation requiring emergency medical treatment. A trauma. Broken bones. A heart attack. A stroke. A seizure. Respiratory distress. A cardiac arrest. The list goes on and on and on. When a critical illness or injury occurs, then, we should all be thankful that we live within a society where emergent, life-saving medical care is available.

Lately, though, it seems the system meant to provide this care is being bogged down by questionable decision-making. Instead of providing emergent care, it seems I spend at least half of my emergency room time now playing doctor to chronic illnesses. To pain control issues. To mildly elevated blood pressure readings. To months of nonspecific weaknesses and fatigue. To office appointments sent to the ER because "we are overbooked today." And our ER is not alone. I hear the frustration of my colleagues and see first-hand how overworked most of us who provide health care in the ER setting have become.

A month back, I was in the middle of a very busy shift. Several patients with chest pain (one requiring immediate catheterization), two patients with respiratory distress (one from skipping dialysis and one from a COPD exacerbation), and three patients from a motor vehicle collision presented almost simultaneously to our ER. Within minutes, all of these critical patients had been treated with efficient, appropriate life-saving care. The team on deserved kudos for doing their job well and making a difference in these patients' outcomes.

Walking back to the nursing station, then, I was surprised to find our secretary being berated by a gentleman in his thirties at the counter. His voice was loud and menacing. His face was pinched with anger. His fists were clenched by his side.

"Whoa," I said, walking up to him, standing between him and the secretary, "what seems to be the problem, sir?"

"We've been waiting two hours to be seen by a doctor!" he exclaimed. "What the hell is going on around here?"

Are you kidding? All he had to do was look for himself to find the organized commotion that was occurring in our ER setting. What followed was the briefest of conversations.

"Sir," I asked, "what brought you to our ER today?""My daughter's left ear is hurting her.""For how long?" I asked."Two hours," he replied.

Two hours of ear pain? I get it--maybe he was worried about his daughter. I would be as well. But my daughter would also have gotten Tylenol and Advil and watched her daddy patiently wait for their turn to be treated once the dire situation had been explained. Better yet, we would have probably waited until the morning when a call could be placed to her personal physician.

I explained to him that we had multiple critical patients brought to us and we would be with his daughter as soon as possible. "We're all trying our best, sir," I added, "but you're going to need to be a little more patient."

The father stared me in the eye. I stared back. Finally, he blurted out what he had been thinking to say. "Well, then," he spoke, sarcasm dripping from his pathetic words, "tryharder." It didn't end there, though. He continued. "This is bullshit waiting two hours to be seen."

Before I could respond, he turned his back and huffed himself back into Room 27 where, the nurse shared with me, his eleven year-old daughter comfortably sat watching TV. "And," the nurse added, "I had already explained to him why they were waiting to be seen."

After this, one of our regulars who had been to our ER over 200 times (since we started tracking in March of 2006) arrived via ambulance. Then a gentleman carrying a big bottle of Mountain Dew was escorted from his ambulance, by foot, into our ER because his main complaint was "I just want to take a nap and was too far from my apartment." Next, an asymptomatic patient with elevated blood pressure for three years, non-compliant with her medications for financial reasons (yes--I noticed the pack of cigarettes hanging from her purse), was sent to us from her family doctor to be cured on the spot. "Go right to the ER," she was told.

Can you appreciate the obviousness of the long waiting times in the emergency department? Although we all pride ourselves on providing expedient care, a four to six hour wait is sometimes the reality for some of our noncritical patients.

As if to hammer the point home, my last patient during my shift that night (I was working 5pm to 3am) was a sixteen year old female who had presented to our ER, via ambulance at 2am, with her mother.

I walked into her room to find this patient and her mother both lying in the cot, laughing while watching TV, the patient in no obvious distress. I introduced myself to them before I started asking questions. "What can I do to help you tonight? What brought you to our emergency room?"

The girl looked at her mother and started giggling, my first sign that she would survive whatever her ailment may be.

"Well," she said shyly, "I've had some burning when I pee for about a week. And," she added, not done "I have something gross leaking from down there (she swept her hand towards her pelvis as she spoke)." Upon further questioning, I learned that she had been diagnosed with a yeast infection from her family doctor one month ago but failed to get her prescription filled. I also learned that she was sexually active with not one, but two partners. Unprotected.

I was disheartened. "What made you come to the ER at 2am when these symptoms have been going on for over a week?" I asked, hoping there was some rhyme or reason to her seeking out emergent care at this time. There wasn't. Her answer to my question--"Why not?" I didn't even approach her on why she came in by ambulance. Some things are better not known, I guess, especially at 2am.

I'm not sure this is the system that was imagined when emergency departments started gaining favor in our society. Don't get me wrong, though. I, like all of my colleagues, are 100% committed to providing respectful and appropriate care to anyone who shows up in our department, whether it be a critical, life-threatening illness or a chronic "nuisance," so to speak.

I can only hope that people will be patient and understanding as we all cope with the evolving changes that seem to be occurring with our health care system. And my hat is off to all the medical folks who work hard, day after day, treating our fellow mankind as best we can within this currently accepted system. Because, even as bogged down as we can sometimes become, what an awesome privilege we have in meeting and greeting and treating our fellow kind. Of helping them out in their time of need.

Salute!!!

As always, big thanks for reading. I wish a blessed holiday season to each and every one of you...

32 comments:

Lars
said...

It always amazes me that there aren't any possibilities for American ER docs to just tell their patients to stop bothering them for such trivial nonsense and leave. Moreover, it's plain silly that paramedics can't refuse patients. Why shouldn't paramedics be able to tell yeast girl they won't bring her to the hospital for a evidently non-urgent, non-life threatening matter. As an European I don't really know much about your legislation, so could you inform me: is it required by law that paramedics always dispatch to calls and adhere to a patients request to be brought to the hospital?

What a great post! I'm not in the medical field, although I used to be an on-call interpreter for ER medical work. I was constantly amazed and confused by the patients' lack of understanding of the word EMERGENCY. Thank you for writing this in such a respectful and thoughtful manner.

My best friend has her own way with the "emergencies" her children present to her. "No one's bleeding, everyone's upright and fed. Now what seems to be the problem." Don't you wish you could at least try to educate people? Seems like you can't tho.

I can't believe these non-emergency "patients" are abusing the ambulance services, and the ER in general. It's mind boggling! I have gone to the ER twice this year, once for a nasty long cut on my leg that I feared was infected (it was), and for a migraine that lasted 3 days and wasn't responding to my normal medications. And both times I felt like I was burdening the system! Great post, like always.

That is amazing! I understand the reason for EMTALA- but I think it needs reformation. Much like many other laws in our nation. Mountain Dew man should definitely be booted on the spot. No wonder healthcare costs are so high!

My daughter waited ALL DAY in ER to be admitted, only to crash two hours later. Ten days later she died. Gone at the age of 34 and no she did not have to die. Had they checked, (or maybe they did but no hmmmm's were raised) they would have realized she had been hospitalized one month prior for two-three days and she was much worse. Her first illness never cleared up.

ER was full of runny noses, snot, ear infections that day but my daughter had to wait all day. Triage seemingly failed her somehow but I wasn't there. I can only rely on her friend's accounts. "Lots of screaming babies" took precedence over my very quiet daughter. You only heard her if she coughed.

On the other side of the coin I am on Medicaid. I saw my primary care doctor for 45 minutes as I have Multiple Sclerosis and renal problems. He billed them about $75 and his reimbursement was $12.43.

My former doctor dropped me when I went on Medicaid so I have no idea what I will do if he drops me. I can't find a urologist or a renal specialist that accepts Medicaid. I guess if I get concerned enough about my renal issues I will go to ER because guess what...by law they must let me see a doctor but of course one must be poliete and wait their turn unless they are dying.

But how do you know you're dying?

I haven't haven't gone to ER for what many would consider "everyday issues" but I will if I can't find a doctor.

As you can see, I have had a hard look at both sides of the same coin.

I am a long time silent reader and fan of your blog. As the wife of an ID physician, I am also very sensitive to the needs of health care professionals. Someone like yeast girl should have had to pay for her ambulance ride.At the same time, I am a non-medical professional and things like a crying 4 year old with an ear ache at 10 pm (and no urgent care clinic) screams ER trip to me if tylenol doesn't work. Someone who is not a medical professional may not be able to differentiate between something that is a true emergency and something that can wait. For us here, because there is no urgent care part of our ER, unfortunately, things like this will continue to clog the system. I have to also add that the wait to get an appointment with your primary here is currently at about 3 months for an existing patient. I'm sure that this clogs our ER too.We almost never go to the ER. Recently, I went to the ER though for terrible left-sided facial pain. I had visited my primary and a dentist with no definitive diagnosis or treatment. One night the pain became unbearable. I got the whole "and why tonight if it has been bugging you for 2 weeks" thing from the nurses and the doctor, which made me feel terrible about coming in. I was apologetic ... embarrassed ... and was brushed right out of the ER. When I returned 3 hours later in terrible pain (I have never done anything like this before ... ever), I was handed off to the PA, who at least was kinder to me about it after suggesting that I might be drug seeking...and I'm sure that it seemed that way to someone who doesn't know me. It was weird and terrible.Later that week, I found myself in the ER yet again ... this time writhing in pain, sucking on ice and sobbing my way through morphine and dilaudid. When these medications did not touch the pain, I was admitted for intractable facial pain and an astute neurologist finally diagnosed me with trigeminal neuralgia and gave me an IV dose of dilantin that put an end to the pain and started me on the path to treatment. The ER is not intended as a place to offer primary care, but sometimes, it can be the gateway to diagnosis and treatment when unexpected symptoms cause pain or discomfort in the middle of the night. I always treat medical professionals with respect and am thankful ... but I found during my recent health care struggle that I was treated like yeast infection girl. Just another point of view here ... and I too found yours to be another in a long line of thought-provoking posts.

I have a chronic health condition that leads to many dislocations and sprains. I can count on one hand the times I have been to the ER. However I can see why some people will use the ER for non emergent issues. I dislocated my wrist really badly and after a month of no recovery (I usually get better after a few days) I made an emergency appointment with my Rheumatologist who wrote up an xray request and told me to go there ASAP as he feared it was fractured (I also have osteoporosis, I am 29). So we go, I explain it to the xray dept, wait an hour to get it xrayed and then told that my rheumatologist would get the results in 10 days! He had written right on it he wanted it read asap and the fear of fracture. They told me to get his office to call over to request the results (it was no closed as the wait was so long) and he could get them in a couple days then. I had it splinted up, taking pain killers and not using it for a week before my rheumy called and said there were no fractures. During this time I had quite a bit of muscle wasteing (again part of my condtion) and had to take quite a while to build up the little strength that I do have.

All of this becasue I didnt want to abuse the ER and go in for a wrist that just wasnt healing. I could have been told right there that there was no fracture and not had to let the muscles get weaker waiting. When I hear of people like Mountain Dew guy or the Yeast infection girl, it just makes me so mad.

I work in Law Enforcement and we also get the people who have no critical thinking skills as well as those who have completely confused their privileges and rights.

that said, I came off my horse a number of years ago. Left foot was facing the wrong way when I sat up, but the pain had not hit yet. The ambulance crew was .outstanding. and when they dropped me off in my cubicle one of the fine young men patted me on the shoulder and said "squeaky wheels get the attention".

I am the daughter of a physician. In my house, we did NOT, complain about much. We were taught very early on to be patient and wait. We were taught that it had better be serious if we went to dad. So I waited. Someone (hospital/barn owner or ambulance crew) called my sister and told her I had broken my ankle. Since there was no way for her to know the severity of my injury and nothing more than the break was communicated to her, she finished her dinner and came to the ER expecting me to be ready to come home. What she found (I don't really remember this) was me clawing at my face and writhing with pain. I had dislocated my heel, totally SHATTERED my ankle, and sheared 2 long pieces off my tib. They had given me nothing for pain and it was hours later, my sister went storming into the intake area and they finally came to deal with me. I spent 4 hours in surgery the next day, and a week in the hospital. It was a 3 month recovery at home with pins and a permanent screw in my ankle. This should never have happened this way. *I* remember seeing my foot going the wrong way before I ever got to the ambulance, so how could the ER have missed that? Also, I was 39 years old at the time, do it was not that I was a minor.

Because I work in LE, I also see the other side of the coin (tho not medically). I see parents who cannot control their kids, women who are mad at their spouses, kids who think we won't let their parents discipline them. All of them expect we will fix the problems they have created. And it makes me incredibly frustrated.

this week i called the dr. after hours (7:30 PM) and of course got the service. Sarge had a fever and they told me to call 24 hrs a day if this happened as his wbc was 200 and he had platelets that day. a doc called me back that had never heard of him, asked me if he had cancer and said to go to the er. it was a cya call from him, and the er was unnecessary.

lucky for us we have dr. wacks and we were able to reach him and he told us what to do and stayed with us until the fever was gone and he was able to sleep all night.

otherwise we'd have been in the er with all the germs around him and that's the last place i wanted him to go.

I heard on the news the other day that a woman had called for an ambulance after she had broken a nail. She was fined! I guess at the other end of the scale you get people like my parents who "don't want to worry the doctors" when it turns out that they are having a heart attack and their appendix has burst! Fortunately both eventually got to the emergency room in time for life-saving treatment.

I've always been bothered by people who abuse the ER but at the same time, I have found ER doctors that have become jaded by this and it has affected their level of care. Fortunately the ER doctor that was working when my daughter was 2 months old, did not brush us off. We took her in for vomitting and it ended up she was in heart failure and needed a heart transplant. If that doctor had brushed us off, like the triage nurse had, as first time over paranoid parents, my daughter would be dead. Since her transplant, we have had occasion to take her to the ER because she is susceptible to getting ill very fast and has had pneumonia a number of times. I had one ER doc who did not even bother to read the info the triage nurse took so was suprised that she had a chest scar. He found no reason for the fever and coughing we had brought her in for, did no chest xray and wrote me a prescription for an antibiotic and told me he was only doing it because she had a fever. Well duh...why do you think I brought her in in the first place? Because I felt like exposing my immune-suppressed daughter to a multitude of other germs in the waiting room? One time I even had a triage nurse, who had been one of our home care nurses, tell us we should probably just go straight to the children's hospital because our local ER docs would just find a reason to send us there anyways after we sat there for hours waiting. Now we bypass our local ER and go straight to the children's hospital even though I know we have to drive an hour just to get a chest xray and a prescription. But I guess it's hard not to become jaded dealing with people who call an ambulance for a yeast infection :)

Great post. I worked at a hospital (in a secretarial position) on the Mex border, and my sister is an RN in the ER at the same hospital that has 3,000 ER visits per month. Yes, 3,000! You can imagine how many of those are real emergencies. My pet peeve: Women who are in labor come across the border to the ER where they can't be turned away and end up having their child in the U.S. making the child a U.S.Citizen. Then they go happily back to Mex and never pay the bill. ARGH!

New reader,an MSIV going into EM, so forgive me for not knowing the answer to this. I assume the only reason the yeast infection was being seen by you was that it was 3am and fast track was closed at your hospital at that hour of the night?

I've read all the comments and lots of interesting thoughts, but I don't see any solutions. Granted, its a HUGE problem that is about the health care system is a whole.

As an idea, I've heard that Walmart is supposedly starting walk in clinics to deal with some of these patients. Has anyone seen these in place? If so, has it had any impact on the numbers and types of cases coming to the ED?

It's too bad...that you have televisions in your ED. Patients have to pay $75/ month here to have a 10" screen on a Canadarm drilled into the wall. Maybe your management can't see the forest for the trees when determining how to improve your ED?

As you also claim here, I don't think people know what an emergency is anymore. At any nick, or cut, people will go online to find out what is wrong. The internet could be to blame for rash decision-making about attending the ER for a mild ear ache that has persisted for two hours.

The ED started in WWI, when soldiers were wounded and needed to be fixed up so that they could go back on the lines. Blood, severe, acute pain, acute mental health breakdown— these are conditions worthy of a trip to the ED.

I completely agree with your post. Yet, at the same time I think a lot of us don't know where the line is between nuisance and critical. Obviously, two hours of ear pain = not critical (they had been waiting for two hours and it had hurt for two hours... what?) Sometimes the line is fine. For example, last fall I was in a car accident and opted against going to the ER. One of the emergency responders said, "I shouldn't tell you this but after an accident, always go to the ER. Especially if the accdient wasn't your fault." In this past semester, we've had a lot of other fine-line experiences where we've had to seriously contemplate if an ER visit would have been appropriate. Dog attack? No ER. Lost fight with a color guard flag? ER. Strep throat? No ER. (but we had to threaten it to get her to go to the doctor)

Love your blog. Generally I'm just a silent follower...but this topic... Anyway, in our neighboring city they have recently opened up a 24 walk in clinic. I'm not terribly sure how much it has helped the two close ERs, but I know if we have an issue with one of the kiddos that can't wait till morning but isn't an emergency it's nice to have a place to go.

Hubby is in the EMS and it's amazing to hear some of the medical calls the fire department has to go out on. I hope someone, someday will be able to find a way to deter people like "yeast girl" from abusing the system. Keep up the great work Doc and Happy Holidays to you and yours!

Myself and friends/family have generally been treated fine by the ER docs. Where the problem has frequently come in was triage.

I myself have been lucky to have only gone to the ER once, per my doctor's instructions. He said I either had a PE, collapsed lung, or pleurisy. I had a friend drop me off, and by the time I got there I could hardly breathe. I was calm talking to the triage desk though, and was wheeled to the far corner of the waiting room. No one re-checked me, and I couldn't stand. So I sat.

Eventually they took me back, and the nurse told the doctor "She's fine, she's just hyperventilating". Doc put one hand on me, said "What's her temperature?" Nurse said it was normal, doc told her to take it again. 104. Then, they all pounced on me with blood draws, blood gas, xrays, etc. (haha not sure I like so many people pouncing on me, but was too weak to resist by then, probably luckily)

Well, it turned out to be pleurisy, so no harm was done. But being quiet and polite didn't work so well in that case. Then the same nurse that had blown me off said as I was leaving "Pleurisy can be very painful" Gee really - Ya think? I didn't notice. I did well to be polite there.

More dangerously, I have a family member with severe asthma. He doesn't wheeze, he gets a silent chest. No we get "No wheeze", and sent to the waiting room despite a note from his asthma doc telling them he progresses rapidly and asking them to treat him promptly. He has been permanently harmed by this. I'm not as nice with triage as I used to be - national standards for asthma care call for immediate treatment, and I've been known to shove this fact in their face.

Other things, I've patiently waited with people for 8 hours to be seen. Your knee hurts - yep, you wait. I completely understand this, and never complain.

But triage blows off important things sometimes too - it is pretty scary really.

Doctor, I wish we could come to your ER - you are truly one of the good ones!

Great post, as always, doc. This is obviously one of the bigger problems in our healthcare system -- almost like EMTALA was designed to grind our system into dust.

In an ideal world you guys wouldn't need the word "Gomer" -- instead, you'd be able to tell them to get the hell out of your ER. Lawyers have ruined that, of course. You know what really sucks? That Hipocratic oath you guys take. I mean, if someone consistently came in and wasted your time, you should be justified in giving them a foley or something!

You know, I've seen this "stuff" rising like a bowl of yeast. Day after day, year after year, the SAME complaints from ER personnel.

I think one way to help out the crush in the ER is to force clinics to have a PA or an NP running an urgent care in their clinic. Force the private practice MD's to shoulder some of the cost of caring for these folks.

A second way to stem the tide of stupid ER visits is to allow the ER to "turf" all of the minor minor stuff back to the patients MD.

Snotty nose for 2 weeks? Itchy skitchy for a month? Then "we will make an appointment right now for you to see you PCP this afternoon!" Don't let the door hit you in th .....on the way out.

After a while the frequent flyers will get the hint and will avoid the ER.

Now don't go all "liberal, progressive, lefty" on me folks...the way we are doing it right now....ain't workin'....so come up with a better idea!

Thank you for such a well written post! I am a medic and we get these pt's everyday but being that they are people I still extend the same care and attention that I would give to an emergent pt. I have learned that the homeless guy that calls ems is really in need of a warm bed in the winter and a meal. The mom of the child with a cold is a first time mom and is still learning. the guy who is the county ems abuser for the smallest complaint is getting over his brothers sudden death and is afraid that he will have a similar fate, all of these pts have, by any medical persons standards, wasted emergency providers time, but I learned that I still helped those people. don't get me wrong I am all about getting the word out on proper use of the ED and EMS system but I now step back and look at the reason behind that persons call to us or visit to the ED.

I thought about this post on Christmas Eve (somewhere around 1am). My aunt's a triage nurse at a doctor's office that only sees walk-ins if they have time in the schedule. This particular day, they were booked all day. A man came in with a cough. My aunt triaged him.

Aunt: Yes, you need to be seen but we're full today. You should go to urgent care. This is how you get there.Mr. Cough: Nah, I'll just go to the Emergency Room.Aunt: I really don't think that's appropriate. This is not an emergency...

Well, at that moment the secretary came in and said there had been a a cancellation and the doctor could see Mr. Cough. Out of spite, Mr. Cough coughed directly in my aunt's face.

Unfortunately, this problem has been present over the majority of my 16 years of ER nursing. It has become so frustrating that many of my experienced, seasoned coworkers have completely quite ER nursing. As of November of 2010, I am sadly, now in that group.

I have figured out when this terrible pattern of misuse of our nations ER's started. It was when EMTALA was passed, in 1998 I think? Before that, we could turn away those without emergent complaints, and turn our attention to those who truly need us.

The college I attend is in a small town. There's no urgent care clinic, but there is a hospital-- so if you don't have access to a doctor in town, or can't be seen by one in the state capitol about an hour and a half away by car (or indeed don't have insurance at all) if your prof is a jerk they'll insist that you get a note from the ER to prove that you were sick. I'd rather take the penalty to my grade than humiliate myself and waste the doctor's time to scribble out a note confirming I had food poisoning/flu/minor problem.

Another frustrating situation for patients is those of us who do for in for emergencies and doctors/staff don't us seriously because they've heard the same thing before from people who didn't have serious problems.

My (diabetic) dad had his toe amputated 2 years ago. It would start bleeding when he put pressure on it. So he'd sit down, the spot would heal for a bit, then when he got up, it'd bleed again. We wrapped his foot up with a trash bag and went to the ED. We told him his toe was bleeding, but they still made us wait (honestly, it didn't look busy from where we were at). When the doc finally came in to see us, she measured how much blood was in the trash bag and it was something like a quart or so. She was amazed that he hadn't passed out yet. But because people come in bleeding and it's nothing serious, we were not taking seriously (we were not panicking yet).

Sorry to vent, but I feel your pain from the only-use-the-ED-in-emergencies patient's point of view.

This comment gives me hope. I thought that it was only in my country with the 'free health care' that we had these problems. Every day I am continually amazed by what patients call emergency, coming by ambulance no less........Anyway, its good to know that I am not alone. Continue doing a good job with your excellent communication skills.

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About Me

I am a father of three. I am an ER physician of 16 years. I am a son, a brother, an uncle, a cousin, a nephew, and a friend, always. I am an athlete. I am small-town. I live in a big town. I am from a large, forestry family. I miss my mother's voice. I enjoy life's simpler, mundane moments. I am humbled daily. I am privileged with many blessings in my life. I am a writer.

Disclaimer

The events and encounters described in this blog are for general discussion and amusement only. They should be considered fiction. Nothing written here should be constituted as medical advice. Although the events of this blog contain certain elemental truths, every attempt has been made to protect patient confidentiality. Names, dates, location, and identifying features have been changed or fictionalized for that reason. The author reserves the right to embellish to make a good story great. All opinions expressed herein are those of the author only. All content is copyright of the author. Please do not reproduce or copy in part or whole without his expressed permission.